Request information about volunteering at HMR

First name*
Middle name(s)
Surname*
Contact phone no*
Email address*
Date of birth*		1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
Nationality
Your sex*		female male

The information that you submit will be held by us (Hammersmith Medicines Research Unit Ltd) for the sole purpose of allowing us to contact you to let you know about studies that you might be able to participate in. We may keep the information about you on paper and in a computer database. If you do take part in a study, some of the information about you may be seen by the organisers of the study, and by the authorities that regulate medicines in the UK and other countries. However, your name would not appear on any of the study documents that we might prepare: we would use only your initials, sex, date of birth and a trial number. By submitting this information, you confirm that you understand and agree with our proposed use of your information. So, you should click the 'submit' button, below, only if you consent to our processing your information as described above.